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Atrial fibrillation / flutter

ADULT

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Chest pain (adult)

  • Suspected acute coronary syndrome
  • Suspected pulmonary embolism or aortic dissection
  • Suspected or confirmed endocarditis, myocarditis or pericarditis
  • Suspected ischaemic chest pain within 24 hours with any of the following concerning features:
    • severe or ongoing chest pain
    • chest pain lasting ten minutes or more
    • chest pain that is new at rest or with minimal activity
    • chest pain that is associated with severe dyspnoea
    • chest pain that is associated with syncope / pre-syncope
    • chest pain that is associated with any of the following signs:
      • respiratory rate > 30 breaths per minute
      • tachycardia >120
      • systolic BP < 90mmHg
      • heart failure / suspected pulmonary oedema
      • ST elevation or depression
      • complete heart block
      • new left bundle branch block 

 Atrial fibrillation

  • Atrial fibrillation / flutter with any of the following concerning features:
    • haemodynamic instability
    • shortness of breath
    • chest pain
    • syncope/pre syncope/dizziness
    • known Wolff-Parkinson-White
    • neurological deficit indicative of TIA/stroke

 Chest pain (paediatric)

  • Current chest pain with haemodynamic compromise
  • Acute onset chest pain from a potential cardiac cause

Heart failure

  • Acute or chronic heart failure with any of the following concerning features:
    • NYHA Class IV heart failure
    • ongoing chest pain
    • increasing shortness of breath
    • oxygen saturation < 90%
    • signs of acute pulmonary oedema
    • haemodynamic instability:
      • pre-syncope / syncope / severe dizziness
      • altered level of consciousness
      • heart rate > 120 beats per minute
      • systolic BP < 90mmHg
    • significant pulmonary or pedal oedema
    • recent myocardial infarction (within 2 weeks)
    • pregnant patient
    • signs of myocarditis
    • signs of acute decompensated heart failure

Hypertension

  • Hypertensive emergency (BP>220/140)
  • Severe hypertensive with systolic BP >180mmHg with any of the following concerning features:
    • headache
    • confusion
    • blurred vision
    • retinal haemorrhage
    • reduced level of consciousness
    • seizures
    • proteinuria
    • papilloedema
  • If suspected pregnancy induced hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric services where possible.

Murmur (adults or children)

  •  New murmur with any of the following concerning features:
    • haemodynamic instability
    • persistent or progressive shortness of breath (NYHA Class III – IV)
    • chest pain
    • syncope / pre-syncope / dizziness
    • neurological deficit indicative of TIA/stroke
    • abnormal ECG (e.g. LV hypertrophy, AF, LBBB, RBBB)
    • fever or constitutional symptoms suggestive of infection (eg endocarditis, acute rheumatic fever)
    • signs of heart failure

Murmur (Infant)

  •  Infant <3 months with newly noted murmur and any of the following concerning features:
    • poor feeding
    • slow weight gain
    • weak or absent femoral pulses
    • post ductal (foot) oxygen saturation < 95%
    • respiratory signs (wheeze, recession or tachypnoea)
  • Suspected heart failure or endocarditis

Palpitations

  • Palpitations with any of the following concerning features:
    • chest pain
    • shortness of breath
    • loss of consciousness
    • syncope / pre-syncope
    • persisting tachyarrhythmia on ECG

 Supraventricular tachycardia

  • Unresolved acute supraventricular tachycardia with any of the following concerning features:
    • syncope
    • severe dizziness
    • ongoing chest pain
    • increasing shortness of breath
    • hypotension
    • signs of cardiac failure
    • ventricular rate >120         

Syncope / pre-syncope

  • Syncope with any of the following concerning features:
    • exertional onset
    • chest pain
    • persistent hypotension (systolic BP <90mmHg)
    • severe persistent headache
    • focal neurological deficits
    • preceded by or associated with palpitations
    • known ischaemic heart disease or reduced LV systolic function
    • associated with SVT or paroxysmal atrial fibrillation
    • pre-excited QRS (delta waves) on ECG
    • suspected malfunction of pacemaker or ICD
    • absence of prodrome
    • associated injury
    • occurs while supine or sitting 

Other

  • Pacemaker/ICD
    • delivery of 2 or more shocks by ICD in 24 hours
    • suspected pacemaker/defibrillator malfunction (with ECG evidence)
    • pacemaker/ICD device erosion
  • Bradycardia including any of the following:
    • symptomatic bradycardia
    • PR interval on ECG exceeding 300ms
    • second degree or complete heart block
  • Broad complex tachycardia
  • Suspected or confirmed endocarditis, myocarditis or pericarditis
  • Not all patients have to be seen by a cardiologist if the general practitioner is comfortable caring for the patient. 
  • In patients with new onset atrial arrhythmias (<48 hours), consider a fast track approach via telephone contact with the nearest cardiology service for consideration of earlier cardioversion to minimize the burden of atrial arrhythmia.

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • New atrial fibrillation/flutter without concerning features 
      • haemodynamic instability
      • shortness of breath
      • chest pain
      • syncope/pre syncope/dizziness
      • known Wolff-Parkinson-White
      • neurological deficit indicative of TIA/stroke
    • Recurrent paroxysmal atrial fibrillation / flutter
    • Atrial fibrillation with signs of heart failure or reduced LV function that does not require presentation to Emergency
  • Category 2
    (appointment within 90 calendar days)
    • Chronic atrial fibrillation requiring management review (e.g. rate control, anticoagulation)

  • Category 3
    (appointment within 365 calendar days)
    • No Category 3 criteria

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Details of relevant signs and symptoms
  • Details of all treatments offered and efficacy
  • Past medical history and comorbidities
  • Family history of cardiac disease or sudden cardiac death
  • FBC, ELFTs, TSH results
  • Include available ECGs, in particular those demonstrating the arrhythmia

3. Additional referral information Useful for processing the referral

  • Any investigations relevant to any co-morbidities
  • Other investigations (if available) eg echocardiogram report, CXR report, holter monitor report, sleep study report
  • History of smoking, alcohol intake and drug use (including recreational drugs)
  • Coagulation studies, magnesium, fasting lipid results
  • CHA2DS2 VASC score

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.